CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2023 ending 06/30/2023 Date of Report:07/25/2023 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 748 1869.500000 69219.5500 37.0257
Subtotal (Total Children Is Unduplicated) 748 1869.500000 69219.5500 37.0257
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 5 7.500000 562.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 3 5.500000 412.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 15 29.000000 1609.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 80 137.000000 10162.5000 74.1788
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 7.500000 562.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 48 82.500000 6187.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 18.000000 1350.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 63 95.500000 7162.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 24 40.500000 2247.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 146 237.500000 13181.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 8.000000 600.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 24.500000 1837.5000 75.0000
Subtotal (Total Children Is Unduplicated) 240 717.000000 47607.7500 66.3985
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 316 1379.750000 68987.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 237 523.250000 26162.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 28 88.000000 6332.4800 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 14 25.500000 1813.0200 71.0988
OCCT-97530TL-OT SESSION BY LICENSED OT 31 93.500000 6728.2600 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 5 10.000000 719.6000 71.9600
PHY-97110-PT SESSION BY LICENSED PT 7 11.000000 791.5600 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 61 276.000000 19824.9800 71.8296
PHY-97110TLGT-PT SESSION BY LICENSED PT 14 17.500000 1259.3000 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 3.000000 215.8800 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 5.000000 359.8000 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 42 193.250000 13906.2700 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 19 40.500000 2914.3800 71.9600
Subtotal (Total Children Is Unduplicated) 540 2666.250000 150015.5300 56.2646
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Total 5252.750000 266842.8300 50.8006
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Number of Children (Unduplicated) With at Least One Service 897
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Center 53
Flag Claims Units Chgs Paid
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R 115 114.500000 7888.4100 0.0000
U 0 0.000000 0.0000 0.0000
B 1313 1196.000000 58778.4900 0.0000
P 2320 2133.500000 104613.6700 104538.2100
D 15 13.500000 725.9800 0.0000
S 101 98.000000 4933.3000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1496 1557.750000 82888.4000 0.0000
Other 174 139.500000 7014.5800 59.2500
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Total 5534 5252.750000 266842.8300 104597.4600